April 5, 2020

Hey there REBEL Cast listeners, Salim Rezaie here.  For me and I am sure many COVID-19 has been quite the whirlwind.  So much information, so little time to process all of it.  Meanwhile, many of us are on the frontlines having to take care of these patients.  Personally, I have never been so wrong, so many times about a single disease process.  What I say today, may be different tomorrow.  This podcast was recorded on April 3rd, 2020 so any information that comes out after this, might change the viewpoints that are expressed today.

April 4, 2020

The protected code blue is designed to keep your staff safe when managing a patient with COVID-19 who has a sudden cardiac arrest. You will continue to do high quality CPR, defibrillation (if indicated), give code medications, and BVM with airway management, now with a drape. I’m going to outline a suggested plan for how to conduct a protected code blue at your hospital. You will need to modify it to fit your hospitals requirements.

REBEL Review 97: Sedation and Analgesia in Drug Shortages

Created April 3, 2020 | Procedures and Skills | DOWNLOAD

April 2, 2020

Background: Peripheral intravenous (PIV) access is one of the most commonly performed invasive procedures in unwell patients.  Although, most patients can have PIVs placed by palpation, there is a subset of patients with difficult vascular access that will require ultrasound-guided peripheral IVs. We have covered this topic before with Jacob Avila (The Ultrasound Podcast, 5 Minute Sono) in REBEL Cast Ep 62. One thing we did not cover was catheter dwell rates.  Catheter dwell rate is an important endpoint as it takes time to perform the procedure, but more importantly for the patient, premature IV failure can include complications such as infiltration, phlebitis, ischemia, necrosis, as well as delays in receiving medications. Therefore, an important concept worth covering is the length of the catheter that is in the vein.

Midline catheters, which we have also covered on REBEL EM are catheters with lengths of 6 to 20cm and represent a potential solution.  These catheters have high success rates and longevity, but insertion requires institutional protocols and specialized training.  A nice go between is the peripheral ultralong catheter (ULC), which is 6.35cm. As with anything new in medicine, it is important to review the evidence to ensure we are performing best practices for our patients.

March 31, 2020

I have been thinking a lot about patients with COVID-19 and the pulmonary pattern that they develop.  This disease process has been categorized like ARDS, but the reality is it is not like "typical" ARDS.  Lung compliance is often normal in these patients, and many patients are not in respiratory distress despite low O2 saturations.  Patients can have a bizarre hypoxemia that does not correlate with their symptoms.  I have even read reports of patients looking comfortable and speaking in full sentences with oxygen saturations in the 40 – 80% range.  There are also more traditional patients in respiratory distress with similar oxygen saturations.  This is a situation where we cannot treat a patient based solely on a number - pulse oximetry may not be a reliable marker of respiratory compromise.

Approaches to oxygen supplementation have stressed minimizing aerosolization of viral particles by avoiding HFNC and NIV.  This appears to be a fear-based statement as opposed to an evidence based one.  If we go straight from nasal cannula to intubation, we will simply run out of ventilators.  Then, more challenges present themselves like rationing mechanical ventilation and trying to figure out how to split ventilators due to the lack of resources.

Finally, I have yet to find a study that shows a mortality rate <50% once a patient is intubated.  Maybe a better way to deal with these patients is an intermediary step using HFNC or CPAP while proning patients while they are awake, before considering intubation.  In this post, I want to review some evidence to support my thoughts on this and, just assume that in every scenario we are discussing full PPE (eye protection, N95/PAPR, gown, gloves, and face shield).